title: Systematic review of anastomotic leakage rate according to an international grading system following anterior resection for rectal cancer.
abstract: BACKGROUND
  A generally acceptable definition and a severity grading system for anastomotic leakages (ALs) following rectal resection were not available until 2010, when the International Study Group of Rectal Cancer (ISGRC) proposed a definition and a grading system for AL.
  
  
  METHODS
  A search for published data was performed using the MEDLINE database (2000 to December 5, 2012) to perform a systematic review of the studies that described AL, grade AL according to the grading system, pool data, and determine the average rate of AL for each grade after anterior resection (AR) for rectal cancer.
  
  
  RESULTS
  A total of 930 abstracts were retrieved; 40 articles on AR, 25 articles on low AR (LAR), and 5 articles on ultralow AR (ULAR) were included in the review and analysis. The pooled overall AL rate of AR was 8.58% (2,085/24,288); the rate of the asymptomatic leakage (Grade A) was 2.57%, that of AL that required active intervention without relaparotomy (Grade B) was 2.37%, and that of AL that required relaparotomy (Grade C) was 5.40%. The pooled rate of AL that required relaparotomy was higher in AR (5.40%) than in LAR (4.70%) and in ULAR (1.81%), which could be attributed to the higher rate of protective defunctioning stoma in LAR (40.72%) and ULAR (63.44%) compared with that in AR (30.11%).
  
  
  CONCLUSIONS
  The new grading system is simple that the ALs of each grade can be easily extracted from past publications, therefore likely to be accepted and applied in future studies.
authors.affiliation: Department of Colorectal Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China ; Digestive Endoscopy Center, Changhai Hospital, Second Military Medical University, Shanghai, China.
authors.forename: Zhi-Jie
authors.initials: ZJ
authors.lastname: Cong
authors.forename: Liang-Hao
authors.initials: LH
authors.lastname: Hu
authors.forename: Zheng-Qian
authors.initials: ZQ
authors.lastname: Bian
authors.forename: Guang-Yao
authors.initials: GY
authors.lastname: Ye
authors.forename: Min-Hao
authors.initials: MH
authors.lastname: Yu
authors.forename: Yun-He
authors.initials: YH
authors.lastname: Gao
authors.forename: Zhao-Shen
authors.initials: ZS
authors.lastname: Li
authors.forename: En-Da
authors.initials: ED
authors.lastname: Yu
authors.forename: Ming
authors.initials: M
authors.lastname: Zhong
mesh_terms: D000714:Anastomosis, Surgical / Q000009:adverse effects*; D057868:Anastomotic Leak / Q000453:epidemiology*; D016208:Databases, Factual; D006801:Humans; D011183:Postoperative Complications / Q000453:epidemiology*; D012004:Rectal Neoplasms / Q000601:surgery*; D054047:Surgical Stomas / Q000009:adverse effects*